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Geriatric best practices in nursing: Helping the patient feel valued
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JOURNAL OF VASCULAR NURSING www.mosby.com/vascnurs
SEPTEMBER 2002
Clinical Forum Geriatric best practices in nursing: Helping the patient feel valued Karen L. Rice, MSN, APRN, BC
Despite a multitude of technologic advances associated with vascular care delivery, patient dignity remains an area in need of improvement. Although “dignity” is a notion frequently associated with a “good death,” it has a broader scope, which encompasses quality of life for the living. This is especially important for those with progressively deteriorating chronic disease. Faced with a rapidly aging population and the complexity of associated vascular disorders, we are all too familiar with the difficulties associated with optimizing the patient’s level of function and autonomy. However, what the health care provider may believe is optimal may not be congruent with the patient’s wishes. In many instances, neither the patient, family, nor health care provider has a clear understanding of what is desired as one transitions through the stages of chronic disease. Time magazine reported that the average American spends more time planning 2 weeks away from work than the last 2 weeks of life– one of the most important transitions of living.1 The advance directive has historically provided some information about personal wishes at the end of life; however, it is frequently limited to basic issues such as whether to resuscitate. Hence, the advance directive frequently fails to provide direction regarding more complex issues such as enteral nutrition and intravenous therapy. Investigations of the decision-making process associated with end-of-life issues have suggested that patients fail to complete advance directives because of misconceptions about the purpose of the document; lack of trust in the health care system; and lack of awareness regarding advance directive decisions. In addition, many who have executed an advance directive fail to communicate their wishes with either their family or health care provider. To improve the dignity associated with health care, the patient must be able to communicate how we can make him or From the Ochsner Clinic Foundation, New Orleans, Louisiana. Reprint requests: Karen L. Rice, MSN, APRN, BC, Ochsner Clinic Foundation, 1516 Jefferson Highway, New Orleans, LA 70121. J Vasc Nurs 2002;20:112-3. Copyright © 2002 by the Society for Vascular Nursing, Inc. 1062-0303/2002/$35.00 ⫹ 0 40/1/127468 doi:10.1067/mvn.2002.127468
her feel valued. It is obvious that this is not a simple task; however, resources are becoming more readily available to both facilitate personal exploration by the patient as well as communication of personal wishes. Five Wishes,2 developed with a Robert Woods Johnson Foundation grant, guides individuals in completing a complex advance directive (living will and health care power of attorney). Upon completion of the workbook, the answered questions include: 1. “The person I want to make care decisions for me when I can’t.” 2. “The kind of medical treatment I want or don’t want.” 3. “How comfortable I want to be.” 4. “How I want people to treat me.” 5. “What I want my loved ones to know.” An important component of Five Wishes is that it provides a forum for the discussion of values, beliefs, and wishes with significant others and health care providers. More detailed information is available at www.agingwithdignity.org. Although several models for the delivery of palliative care exist, Chochinov3 describes a new model, called dignity-conserving-care. This model not only comprises what one does to patients, but how one values patients. The following 3 broad areas exerting influence on individual perceptions of dignity form the basis of the dignity-conserving-care model: 1. Illness-related concerns These concerns are directly related to the results of illness and include symptom distress (physical and psychologic elements) and level of independence (cognitive and functional levels). 2. Dignity-conserving repertoire Factors influencing sense of dignity include the many aspects of the patients’ psychologic and spiritual makeup. As described in the model, this includes dignity-conserving perspectives (coping mechanisms) and dignity-conserving practices (techniques to bolster one’s sense of dignity). The dignity-conserving perspectives include the following 8 subthemes: continuity of self, role preservation, maintenance of pride, hopefulness, autonomy/control, generativity/legacy, acceptance, and resilience/fighting spirit. The following 3 subthemes define the dignityconserving practices: living in the moment, maintaining normalcy, and finding spiritual comfort.
Vol. XX No. 3
JOURNAL OF VASCULAR NURSING www.mosby.com/vascnurs
3. Social dignity inventory Characteristics, which define the social dignity inventory, reference social issues or relationship dynamics that affect a patient’s sense of dignity. These defining characteristics include the 5 following subthemes: privacy boundaries, social support, care tensor, burden to others, and aftermath concerns. The dignity-conserving care model encompasses general influences on dignity; however, each individual will ascribe varying degrees of importance to each of its components. Similarly, the concept of dignity may vary from individual to individual, as well as between one circumstance and the next. The challenge to health care providers is to understand how an individual patient/family perceives dignity so that appropriate strategies may be facilitated.4 In a recent JAMA5 article, Chochinov discusses a series of questions found to be helpful in eliciting information about the patient’s values and beliefs. Both Five Wishes and the dignity-conserving-care model may be useful resources in not only developing treatment plans for patients requiring palliative care, but more importantly, for those diagnosed with chronic diseases. Both of these resources provide individuals with a mechanism that forces people to think about the gray areas of health care choices in a relaxed atmosphere. These resources facilitate the development of a plan
PAGE 113
during a time when one has the energy to deal with these issues, rather than during the urgency associated with acute illness. The goal of integrating the advance directive process into the treatment of chronic disease is to make time with families a time of dignity and not one of hurried choices. Finally, this process of preparation may ultimately enhance the relationship between patients, families, and health care providers while a course of treatment congruent with the patient’s wishes is formulated. In conclusion, it is through both including the patient/family in the development of plans of care and honoring wishes that we will make patients feel valued.
REFERENCES 1. Cloud L. A kinder, gentler death. Time 2000;September 18: 60-7. 2. Five Wishes. Tallahassee (FL): Aging With Dignity; 2000. 3. Chochinov HM. Dignity-conserving-care—a new model for palliative care: helping the patient feel valued. JAMA 2002; 287:2253-60. 4. Gabany JM. Factors contributing to the quality of end-of-life care. J Am Acad Nurse Pract 1997;12:472-4. 5. Meisel A, Snyder L, Quill T. Seven legal barriers to end-oflife care: myths, realities, and grains of truth. JAMA 2000; 284:2483-8.
JOURNAL OF VASCULAR NURSING www.mosby.com/vascnurs
SEPTEMBER 2002
Clinical Forum Geriatric best practices in nursing: Helping the patient feel valued Karen L. Rice, MSN, APRN, BC
Despite a multitude of technologic advances associated with vascular care delivery, patient dignity remains an area in need of improvement. Although “dignity” is a notion frequently associated with a “good death,” it has a broader scope, which encompasses quality of life for the living. This is especially important for those with progressively deteriorating chronic disease. Faced with a rapidly aging population and the complexity of associated vascular disorders, we are all too familiar with the difficulties associated with optimizing the patient’s level of function and autonomy. However, what the health care provider may believe is optimal may not be congruent with the patient’s wishes. In many instances, neither the patient, family, nor health care provider has a clear understanding of what is desired as one transitions through the stages of chronic disease. Time magazine reported that the average American spends more time planning 2 weeks away from work than the last 2 weeks of life– one of the most important transitions of living.1 The advance directive has historically provided some information about personal wishes at the end of life; however, it is frequently limited to basic issues such as whether to resuscitate. Hence, the advance directive frequently fails to provide direction regarding more complex issues such as enteral nutrition and intravenous therapy. Investigations of the decision-making process associated with end-of-life issues have suggested that patients fail to complete advance directives because of misconceptions about the purpose of the document; lack of trust in the health care system; and lack of awareness regarding advance directive decisions. In addition, many who have executed an advance directive fail to communicate their wishes with either their family or health care provider. To improve the dignity associated with health care, the patient must be able to communicate how we can make him or From the Ochsner Clinic Foundation, New Orleans, Louisiana. Reprint requests: Karen L. Rice, MSN, APRN, BC, Ochsner Clinic Foundation, 1516 Jefferson Highway, New Orleans, LA 70121. J Vasc Nurs 2002;20:112-3. Copyright © 2002 by the Society for Vascular Nursing, Inc. 1062-0303/2002/$35.00 ⫹ 0 40/1/127468 doi:10.1067/mvn.2002.127468
her feel valued. It is obvious that this is not a simple task; however, resources are becoming more readily available to both facilitate personal exploration by the patient as well as communication of personal wishes. Five Wishes,2 developed with a Robert Woods Johnson Foundation grant, guides individuals in completing a complex advance directive (living will and health care power of attorney). Upon completion of the workbook, the answered questions include: 1. “The person I want to make care decisions for me when I can’t.” 2. “The kind of medical treatment I want or don’t want.” 3. “How comfortable I want to be.” 4. “How I want people to treat me.” 5. “What I want my loved ones to know.” An important component of Five Wishes is that it provides a forum for the discussion of values, beliefs, and wishes with significant others and health care providers. More detailed information is available at www.agingwithdignity.org. Although several models for the delivery of palliative care exist, Chochinov3 describes a new model, called dignity-conserving-care. This model not only comprises what one does to patients, but how one values patients. The following 3 broad areas exerting influence on individual perceptions of dignity form the basis of the dignity-conserving-care model: 1. Illness-related concerns These concerns are directly related to the results of illness and include symptom distress (physical and psychologic elements) and level of independence (cognitive and functional levels). 2. Dignity-conserving repertoire Factors influencing sense of dignity include the many aspects of the patients’ psychologic and spiritual makeup. As described in the model, this includes dignity-conserving perspectives (coping mechanisms) and dignity-conserving practices (techniques to bolster one’s sense of dignity). The dignity-conserving perspectives include the following 8 subthemes: continuity of self, role preservation, maintenance of pride, hopefulness, autonomy/control, generativity/legacy, acceptance, and resilience/fighting spirit. The following 3 subthemes define the dignityconserving practices: living in the moment, maintaining normalcy, and finding spiritual comfort.
Vol. XX No. 3
JOURNAL OF VASCULAR NURSING www.mosby.com/vascnurs
3. Social dignity inventory Characteristics, which define the social dignity inventory, reference social issues or relationship dynamics that affect a patient’s sense of dignity. These defining characteristics include the 5 following subthemes: privacy boundaries, social support, care tensor, burden to others, and aftermath concerns. The dignity-conserving care model encompasses general influences on dignity; however, each individual will ascribe varying degrees of importance to each of its components. Similarly, the concept of dignity may vary from individual to individual, as well as between one circumstance and the next. The challenge to health care providers is to understand how an individual patient/family perceives dignity so that appropriate strategies may be facilitated.4 In a recent JAMA5 article, Chochinov discusses a series of questions found to be helpful in eliciting information about the patient’s values and beliefs. Both Five Wishes and the dignity-conserving-care model may be useful resources in not only developing treatment plans for patients requiring palliative care, but more importantly, for those diagnosed with chronic diseases. Both of these resources provide individuals with a mechanism that forces people to think about the gray areas of health care choices in a relaxed atmosphere. These resources facilitate the development of a plan
PAGE 113
during a time when one has the energy to deal with these issues, rather than during the urgency associated with acute illness. The goal of integrating the advance directive process into the treatment of chronic disease is to make time with families a time of dignity and not one of hurried choices. Finally, this process of preparation may ultimately enhance the relationship between patients, families, and health care providers while a course of treatment congruent with the patient’s wishes is formulated. In conclusion, it is through both including the patient/family in the development of plans of care and honoring wishes that we will make patients feel valued.
REFERENCES 1. Cloud L. A kinder, gentler death. Time 2000;September 18: 60-7. 2. Five Wishes. Tallahassee (FL): Aging With Dignity; 2000. 3. Chochinov HM. Dignity-conserving-care—a new model for palliative care: helping the patient feel valued. JAMA 2002; 287:2253-60. 4. Gabany JM. Factors contributing to the quality of end-of-life care. J Am Acad Nurse Pract 1997;12:472-4. 5. Meisel A, Snyder L, Quill T. Seven legal barriers to end-oflife care: myths, realities, and grains of truth. JAMA 2000; 284:2483-8.